Total IVC occlusion as an unusual cause of acute renal failure after orthotopic liver transplantation

Renal dysfunction before and after orthotopic liver transplantation (OLT) has significant implications for morbidity and mortality of these patients. We describe the management of a 72-year-old male patient with history of alcoholic liver cirrhosis (MELD 38) undergoing OLT. The patient presented with declining renal function prior to OLT (baseline GFR,25 mL/min) due to diuretic therapy for refractory ascites, hypovolemia postgastrointestinal bleed, and possible hepatorenal syndrome. The intraoperative management was complicated by preexisting anemia (hematocrit, 22%), unusual RBC antibody (anti-JKa) and significant surgical blood loss. To achieve surgical hemostasis, temporary clamping of the inferior vena cava (IVC) caudal to the transplanted liver was necessary. Postoperatively, the patient remained anuric despite appropriate fluid resuscitation. Renal replacement therapy was initiated to balance volume and acid-base status. A venogram on postoperative day (POD) 5 indicated a complete IVC occlusion and caval thrombectomy was performed on POD 6. After restoration of venous renal drainage, renal function improved and renal replacement therapy was weaned. Renal function indicators normalized in 8 weeks, and remained unimpaired up to 3 months post-OLT. Unintended complete obstruction of the suprarenal IVC may occur during OLT to control surgical bleeding, and should be considered as a cause for acute renal failure after liver transplant. Despite the preexisting renal dysfunction, renal function quickly improved after restoration of blood flow drainage and normalized in less than 8 weeks post obstruction.